IrishMedicalJournal

OfficialJournaloftheIrishMedical Organisation

˜ Established 18

67 ˜

APRIL 2013 Volume 106 ■ Number 4

99 This MonthIMJ Commentary

100 Antibiotic Resistance is becoming a MainstreamChallenge to Public Health

Editorial101 Managing Physical Health in Mental Health Populations

MMcCormack, P Connolly, E Lawlor, M Clarke, A Lane

Original Papers102 Bicycle Helmet Wearing in a Sample of Urban

Disadvantaged Primary School ChildrenMB Quirke, S McGilloway, CM Comiskey, C Wynne, K O’Sullivan,E Hollywood

105 STEPS: Lean Thinking, Theory of Constraints andIdentifying Bottlenecks in an Emergency DepartmentA Ryan, K Hunter, K Cunningham, J Williams, H O’Shea, P Rooney,F Hickey

107 Prevalence of Subclinical and Undiagnosed OvertHypothyroidism in a Pregnancy Loss ClinicAS Khalid, C Joyce, K O’Donoghue

110 Factors Affecting Receipt of a Medical Card in a Cohort ofColorectal Cancer Patients, 2002-2006J McDevitt, L Sharp, D MacDonald, F Dwane, H Comber

113 General Practitioners’ Perspectives on Revised Entry andSelection Methods to Medicine and the HPATT Dennehy, M Kelly, S O`Flynn

116 Patient Knowledge of Peripheral Vascular Disease in anOutpatient Setting: An Achilles Heel?M Owens, H Mohan, MA Moloney, G Roche-Nagle, J Baker, S Sheehan,D Mehigan, M Barry

Research Correspondence118 Smoking in Vehicles is Lower than Mobile Telephone Use

While Driving, but is Socially PatternedI Gilroy, N Donnelly, W Matthews, K Doherty, G Conlon, AT Clarke,L Daly, C Kelleher, P Fitzpatrick

120 Parental Experience of Enzyme Replacement Therapy forHunter SyndromeM Buraczewska, D O’Leary, O Walsh, A Monavari, E Crushell

Occasional Piece122 The World Health Organisation Analgesic Ladder:

Its Place in Modern Irish Medical PracticeL Balding

Letters to the Editor124 Best for the Child or to Reassure the Doctor!

TI Hassan, C Martin

125 Unknown Knowns – Where Did the DAMAs Go?A Akintola, R Liston, D Byrne, J Farrelly

125 The Cricoid Cartilage – A Useful Palpable Landmark toIdentify The Recurrent Laryngeal NerveW Hasan, A Curran

127 Combined Endobronchial and Endoscopic Ultrasound-guided Fine Needle Aspiration: A One Stop Approach inDiagnosing and Staging Lung CancerP Nadarajan, S Sulani, D O’Toole, F O’Connell

Book Review98 Urgent Care Emergencies – Avoiding the Pitfalls and

Improving the Outcomes

126 Classifieds127 Continuing Professional

Development

98 Original PaperIrishMedicalJournalApril2013Volume106Number4www.imj.ie

Book Review98

EditorJFA Murphy, FRCPI

Assistant to the EditorLorna Duffy

Editorial Advisory BoardR Daly, FRCPL Daly, PHD (Biostatistics)B Day, MRCGPD Magee, FRCSIC O’Herlihy, FRCOGD Powell, FRCPIM Patton, FRCP

Director of Finance & AdministrationSusan Clyne

IMO Management CommitteeDr Paul McKeown (President)Dr Matthew Sadlier (Vice President)Professor Sean Tierney (Hon Treasurer)Dr Brett Lynam (Hon Secretary)Dr Trevor Duffy (Chair, Consultant Committee)Dr Ray Walley (Chair, GP Committee)Dr Mary Conlon (Chair, PHD Committee)Dr Mark Murphy (Chair, NCHD Committee)Dr Ronan Boland (Immediate Past President)

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© Irish Medical Journal 2012. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any other means – electronic, mechanical,photocopying, recording or otherwise without prior permission in writing from the Irish Medical Journal.

The authors of this book state that it was developed to helpproviders who evaluate low acuity complaints in any setting, withits aim being to highlight common pitfalls in the management ofseemingly low-acuity conditions. They deliberately set out thatthe text was not meant to be comprehensive in scope, but ratherbeing meant to bring the provider’s attention to high risk aspectsof chief complaints that may be encountered in these low-acuitysettings. That, in essence, is the scope of the book, but it is one ofits failings, unfortunately.

Throughout the chapters it highlights the various pitfalls thatrelate to clinical conditions that might beencountered in the urgent care setting,which are useful. Unfortunately, however,the book does not provide any formsystematic, practical approach to thevast majority of the clinical conditions itdeals with, which limits its usefulness.Highlighting the pitfalls of day to daypractice, without advising of a practicaland systematic approach to commonclinical conditions limits this book’susefulness. A good example of thelimitations of the text is contained withinthe first chapter, which concentrates onhead, eye, ear, nose and throat pitfalls.The section on the eye concentrates,in the main, on corneal abrasions, eyeforeign bodies and hyphaema, withonly a cursory mention of more seriousconditions which are not commonlyseen (and are thus not uncommonlymisdiagnosed), such as central retinalartery and vein occlusion, acute angleclosure glaucoma and retinal detachment.

Whilst there are two “key facts” highlighted in this section, thereis actually no highlighting of the many pitfalls that relate to theselatter conditions, of which there are many. Another example ofa failure to deal with important topics would be the chapter on“The evaluation and management of back pain”, which makesno mention of sciatica, which is a very significant deficit for acommonly presenting problem.

Unfortunately, there are also a number of factual inaccuracieswithin the text. A particular example is the statement that an x-rayat 10 days, in a patient with a suspected scaphoid fracture, will

reveal sclerosis i.e., healing at the fracturesite. An x-ray at 10 days in a patient witha scaphoid fracture will, at best, reveal thefracture line alone, as it takes at least 4weeks for scaphoid new bone formationto become evident radiologically. Thefinal chapter “Talking the talk: effectivecommunication in urgent care” is good andit is applicable to all medical practice, notjust urgent care medicine. The small gemsof information within that chapter obviouslyreflect the experience of the authors inhaving ‘being around the block’, in termsof clinical care. Another positive is thatthe tables, photographs, and x-rays are allgenerally of good quality.

Overall though, whilst there are somepositive elements to this book, it has toomany weaknesses for me to recommend itas a useful and practical text.

A GleesonDepartment of Emergency Medicine,Beaumont Hospital, Beaumont, Dublin 9

Urgent Care Emergencies – Avoiding the Pitfalls andImproving the OutcomesEditors: Deeti G. Goyal and Amal Mattu

Publisher: Wiley-Blackwell

99This Month

IrishMedicalJournalApril2013Volume106Number4www.imj.ie

Bicycle Helmet Wearing in a Sample of UrbanDisadvantaged Primary School Children: Quirke et al statethat there are 7 deaths and 263 hospital admissions amongcyclists involved in RTAs.Children under 15 years areat greatest risk. In this studythe authors found that helmetwearing was not commonpractice and 50% of childrendidn’t wear a helmet. Two thirdsof 12/13 year olds never worea helmet. There was a genderdifference, 61% of girls wore ahelmet but only 39% of boys.

STEPS: Lean Thinking, Theory of Constraints andIdentifying Bottlenecks in an Emergency Department:Ryan et al have undertaken an analysis of the factors that

adversely affect patientflow through ED. Patientsrequiring radiology (4.4times), patients needingblood tests (4.1 times) andpatients needing admission(7.7 times) were morelikely to be in ED greaterthan 4 hours. One of thesolutions adopted at theauthors’ hospital has beenthe opening of a 12 bedacute medical and surgicalassessment unit.

Prevalence of Subclinical and Undiagnosed OvertHypothyroidism in a Pregnancy Loss Clinic: Khalid etal have examined the prevalence of subclinical and clinicalhypothyroidism among women attending a pregnancy loss clinical.There were 262 women included in the analysis, the maternalage ranging from 18-47 years. The authors found that 8.39%of women had subclinical hypothyroidism and 3.05% had overthypothyroidism. The findings support the association betweenhypothyroidism and pregnancy loss.

Factors Affecting Receipt of a Medical Card in a Cohortof Colorectal Cancer Patients: McDevitt et al have examinedthe factors that determine whether a patient obtains a medicalcard after the diagnosis of colorectal cancer. At the time of thestudy anybody over 70 years wasautomatically entitled to a medicalcard. During the study period 2002-2006 there were 10,284 casesof colorectal cancer. There were4762 patients under 70 years ofwhom 1547 already had a medicalcard before the diagnosis. Of theremaining 3215 patients, 1435(45%) subsequently were granted amedical card based on factors suchas younger age, greater deprivation,the need for aggressive treatmentand living in a rural area.

General Practitioners’ Perspectives on Revised Entry andSelection Methods to Medicine and the HPAT: Dennehyet al have surveyed the attitudes of GPs to the HPAT, which hasbeen part of medical school entry requirements since 2009. Themajority of the 122 GP respondents had little knowledge of theHPAP. On third of the GPs disagreed with the HPAT while themajority strongly supported the Leaving Certificate as a selectiontool. The respondents performed well with the 3 sample HPATquestions posed to them.

Patient Knowledge of Peripheral Vascular Disease inan Outpatient Setting: An Achilles Heel? Owens et alhave assessed the level of patientknowledge about the risk factors andsecondary prevention of peripheralvascular disease. Two thirds ofpatients were aware that smokingwas an important factor. However,there was little understanding of theimportance of diabetes, hypertensionand hypercholesterolaemia. Increasedcommunity awareness of this conditionis recommended.

Smoking in Vehicles is Lower than Mobile Telephoneuse while Driving, but is Socially Patterned: Gilroy et alundertook an observational study of 2230 cars to determine thefrequency of smoking by drivers and passengers, and mobilephone use by drivers. Smoking was observed in only 1.36% ofcars while 2.56% of drivers were observed using their phones.

The authorssuggest thatthe proposedlegislationbanningsmoking incars maybe labourintensive fora low yield.

Parental Experience of Enzyme Replacement Therapyfor Hunter Syndrome: Buraczewska et al describe the variedcomponents in the enzyme replacement management of HunterSyndrome. In a series of 9 cases, the authors report that following2 years of treatment, hepatomegaly was reduced 85%, respiratorysymptoms 67%, urinary glycosaminoglycan 62%. The treatmentregimen placeda considerablestrain on familiesas the childrenspend 7 hoursweekly in hospital.The introductionof home basedtreatment wouldbe beneficial.

In This Month’s IMJ

Table 1 T4 and TSH values in pregnancy loss and control groups in comparison to relevant pregnancy trimester-specific reference standards,defined as median, 2.5% and 97.5% quartiles (Reference Intervals for Children and Adults Elecys Thyroid Tests, Roche; EstablishingTrimester Specific Maternal Thyroid Function Reference Intervals, Khalid et al, unpublished)

RecurrentMiscarriage

FirstTrimesterControl

FirstTrimesterReferenceStandard

LateMiscarriage

SecondTrimesterControl

SecondTrimesterReferenceStandard

StillbirthThird Trimester

Control

Third TrimesterReferenceStandard

Median T4pmol/L 15.70 14.40 15.4 14.00 12.80 12.9 15.00 11.40 11.9

Range T4pmol/L 11.40 – 36.30 11.62-19.24 12.05- 19.60 8.40 -19.20 10.30-16.60 9.63- 17.00 10.20- 20.20 8.30-15.59 8.39- 15.60

Median TSHmIU/L 1.60 1.08 1.48 1.69 1.60 1.52 2.13 1.59 1.42

Range TSHmIU/L 0.41- 7.46 0.11-3.25 0.33- 4.59 0.32- 6.15 0.55-3.13 0.35- 4.10 0.39- 6.35 0.55-3.91 0.21- 3.25

Table 1 GPs’ opinions on the appropriateness of a variety of tools used for selectionto medicine

Appropriatenessof selectiontool

Aptitudetest

LeavingCert

Interview PersonalStatement

Knowledgeof theCourse

Personalitytraits

1-stronglyagree

n=17(13.9%)

n=51(41.8%)

n=20(16.4%)

n=6(4.9%)

n=11(9%)

n=19(15.6%)

2 n=68(55.7%)n=67(54.9%)

n=47(38.5%)

n=19(15.6%)

n=39(32%)

n=44(36.1%)

3 n=19(15.6%)n=1(0.8%)

n=19(15.6%)

n=21(17.2%)

n=18(14.8%)

n=28(23%)

4 n=6(4.9%)n=1(0.8%)

n=13(10.7)

n=35(28.7%)

n=24(19.7%)

n=15(12.3%)

5-stronglydisagree

n=6(4.9%)

n=0(0%)

n=17(13.9%)

n=29(23.8%)

n=21(17.2%)

n=10(8.2%)

Non responders n=6(4.9%)n=2(1.6%)

n=6(4.9%)

n=12(9.8%)

n=9(7.4%)

n=6(4.9%)

Table 3 Strategiesfor SymptomImprovement

NSmoking Cessation 24Exercise 35Diet 10Medications 4Surgery 2Combination of the Above 16Don’t Know 27Other 11

Table 1 Prevalence of smoking or mobile telephone use overall andaccording to location

Prevalence Smoking Mobile Telephone Usen/N % n/N %

Overall 31/2230 1.39 57/2230 2.56

Location Booterstown 11/1146 0.96 48/1146 4.18Dorset Street 20/1084 1.85 9/1084 0.83

Time Morning 11/776 1.41 26/776 3.35Lunchtime 8/726 1.1 17/726 2.34Afternoon 12/728 1.64 14/728 1.92

100 CommentaryIrishMedicalJournalApril2013Volume106Number4www.imj.ie

The Saturday Financial Times1 16th March ’13 carried a full-pagearticle on antimicrobial resistance. The article was in response tothe annual Report of Dame Sally Davies, the UKs Chief MedicalOfficer2. Her Report emphasised the growing global problem ofantibiotic resistant ‘superbugs’. Seven per cent of all deaths aredue to infection. She warned British politicians of an ‘apocalypticscenario’ of insufficient antibiotics. She also referred to it a ‘tickingtime bomb’. She wants the issue discussed at the next G8 Summitin London. She said that antimicrobial resistance represents athreat that may be as important as climate change for the world.Her US counterpart Thomas Frieden at the Centre for DiseaseControl has recently spoken about the ‘nightmare bacteria’,the Carbapenem-resistant Enterobacteria. One of Sally Daviesconcerns is the under-provision of new antibiotics. She pointedout that there hasn’t been a new class of antibiotics developedsince the late 1980s. She has held meetings with industry inorder to stimulate new antibiotic productions. The obstacles topharmaceutical companies developing new antibiotics are the highcosts in their generation, their short term use compared with drugsfor chronic conditions and the limited sales market secondary to thepolicy of ‘saving’ new antibiotics for serious infections. Andrew Wittyat GlaxoSmithKline said that there is a need for greater rewards forthose companies involved in the production of new antibiotics.The banner statistics are alarming. It is estimated that 25,000patients die annually in the EU from drug-resistant bacteria. Theseserious infections are costing billions of Euros in terms of additionalhealthcare. The rise in international travel has facilitated thespread of resistant organisms. It would appear that concerns aboutantibiotic resistant infections have spread beyond the academiccorridors of microbiology and have now reached everyday clinicalpractice and the public consciousness. There are multiple reasonsfor the development of resistance. There is an excessive and ill-controlled use of antibiotics particularly for viral infections. In manyEU countries medications can be obtained without a doctor’sprescription. The use of antibiotics in animal husbandry is also aconcern in the development of cross-resistance.Resistant microorganisms are those that are not inhibited byantibiotics. The resistance to treatment starts as a random mutationin the bacteria’s genetic code. Antibiotic resistance has steadilyincreased since systemic antibiotics were introduced in the 1930sand 1940s. The new concern, however, is the breath of resistanceand the shortage of new antibiotics being produced. Increasednumbers of critically ill susceptible patients are being nursed inclose proximity in our intensive care units. The real danger is thegram-negative Enterobacteriaceae such as E.Coli and Klebsiella.E.Coli alone accounts for 36% of bacteraemias. Multi-resistantE.Coli septicaemia has a 30% mortality while the mortality is15% in those with a susceptible E.Coli. Extended Spectrum BetaLactamase (ESBL) producing organisms are causing increasedconcern. These organisms produce a lactamase capable ofbreaking the beta lactam ring of the antibiotic when deactivates itsefficacy. An ESBL-producing E Coli strain, which is more difficultto treat than MRSA, affects 30,000 patients annually in the UK.The first case of ESBL presented 4 years ago. ESBL producingantimicrobials are resistant to cephalosporin antibiotics.A typical large 1,000 bed acute hospital will have 500bacteraemias involving Gram-negative bacteria, 15% being multipleantibiotic resistant. In addition there will be 60 cases of C.difficileand 3 cases of MRSA.The concept of antimicrobial stewardship is being widely promoted.Its goals are the optimal use of antibiotics for the individual patients,the prevention of overuse and to minimise resistance at patientand community levels. The problem is how to balance betweenthe appropriate early use of antibiotics in the face of potentiallysevere infections and the inappropriate use of antibiotics for minorillnesses. The first step is the institution of antibiotic guidelines inall hospitals which should avoid broad-spectrum antibiotics where

possible. Try to avoid antibiotics that lead to multi-resistant bacteriaor C.difficile. The justification for the commencement of theantibiotics should be entered in the case notes. Blood culture andall other appropriate swabs should be taken before commencingtherapy. Prescribe the shortest, effective course. One of thelimitations that diagnostics other than the blood culture such asC-reactive protein and white cell counts lack specificity. During theperiod awaiting the blood culture the treatment is a ‘best guess’.There have been a number of gains and successes in the area ofinfection prevention. There has a welcome reduction in the numberMRSA bacteraemias. In England in 2011 there was an 84.7%reduction in MRSA septicaemias compared with 2004, 1,185 casescompared with 7,700 cases. Since 2008 the C.difficile cases havereduced by 53%. This has been achieved by a number of measures.There has been a concerted effort to improve hand washing. The5 moments of hand washing developed by the WHO are- beforetouching the patient, before a clean or aseptic technique, afterbody fluid exposure risk, after touching a patient, after touchingthe patient’s surroundings. There has also been a major drive toprevent medical device infections. he prevention of catheter-relatedbloodstream infection has been spearheaded by Peter Pronovost3and his team at Michigan. He demonstrated that meticulous linecare can reduce line infection by 60%. The bundle of interventionsnow considered a standard of care are hand washing, useof chlorhexidine for skin antisepsis, use of maximum sterileprecautions for catheter insertion and dressing changes, avoidanceof the femoral vein and prompt removal of unnecessary catheters.Vaccines have played an important role for children. TheStreptococcal pneumonia vaccine has been effective in reducinginvasive infections including pneumonia, meningitis.In Ireland the Strategy for the Control of Antimicrobial Resistancein Ireland (SARI) was established in 2001. For over a decade itpromoted the prudent use of antibiotics, surveillance and infectioncontrol. The HIQA infection control standards were launched in2009. In 2011 SARI handed over its functions to the NationalHealth Care Associated Infection (NHAI) Clinical Programme. Theprimary aim is the prevention and control of antimicrobial resistanceand healthcare associated infection. It measures compliance withstandards. The Programme’s workstreams include hand hygiene,hospital antimicrobial stewardship, medical device infectionprevention and avoidance of surgical site infection. There is anemphasis on guidelines for the large scale usage of antibioticsconditions such as urinary tract infection. The use of antibioticsin long term facilities is also being addressed. There are publiceducation activities such as ‘antibiotics don’t cure colds or the ‘flu’,European antibiotic day, and WHO hand hygiene day.It is clear that concerns about antibiotic resistant bacteria areincreasing. It is now a public health issue. The relative paucity ofnew antibiotics means that the emphasis must be on infectioncontrol and prevention. In children a comprehensive, effectivevaccination is of paramount importance. The Report of Sally Davieshas added a new stimulus for all those involved in the process.One of the final comments in her Report is that in the last 50 yearswe had a wide array of agents to fight infection but the next 50years may be very different with the emergence of highly resistantbacteria.JFA MurphyEditor

1. Jack J. Chief medic to launch superbug campaign. Financial Times16th March 2003 page 3.

2. Annual Report of Chief Medical Officer. Infections and the rise ofantimicrobial resistance. Volume 2. 2013

3. Provonost P, Needham D, Berenholtz S, Sinopoli D, Chu H, CosgroveS, Sexton B, Hyzy R, Welsh R, Roth G, Bander J, Kepros J, Goeschel C.An intervention to decrease catheter-related blood stream infections inthe ICU. N Engl J Med 2006;355:2725-2732.

Antibiotic Resistance is becoming a Mainstream Challenge toPublic Health

101Editorial

IrishMedicalJournalApril2013Volume106Number4www.imj.ie

People with serious mental illness (SMI) have greatly increasingmorbidity and mortality from physical illness than the generalpopulation. This results in a 25 to 30 year shorter life expectancywith cardiovascular disease being the leading cause of death1.It has been suggested that current policy, services and healthpromotion actions are ineffective in targeting physical illness inthis population.

Vulnerabilities for Physical Health DifficultiesExcess mortality seen in the psychiatric population reflectsmultiple vulnerabilities and risk factors including poverty,unemployment, being single and marginalised have been reported.Lifestyle risks include a poor diet, increasing smoking andsubstance abuse rates and lower levels of exercise2. Althoughthere may be a genetic predisposition to develop metabolicabnormalities in schizophrenia, the impact of negative symptomsof illness such as difficulties in concentration and memory and alack of motivation is also significant3. This is compounded by thefinding that people with mental illness have inadequate accessto good quality physical healthcare and that they receive poorertreatment for physical disorders (‘diagnostic overshadowing’)than the general population4. The potential of antipsychoticmedications to cause significant weight gain and other metabolicside effects leaves this population at high risk of physical illness.

Targeting Physical HealthThe chief risk factors for mortality are lipid abnormalities,diabetes, high blood pressure, smoking, physical inactivity, obesityand stress5. A recent review found that the top modifiable riskfactors for premature mortality could be lowered in patients withschizophrenia5. The dilemma for health care services lies in thediffering focus between physical and mental health providers, andthe finding that those with mental health problems do not attendto their physical health. There are clear benefits to monitoring andmanaging risk factors for physical illness. It is argued that patientswith serious mental illness are less capable than other patients ofinterpreting physical signs of ill health, suggesting the need for anincreased role for either primary or secondary care to monitor thephysical health needs of these patients4.

NICE guidelines acknowledge the risk of increased physicalmorbidity and mortality in individuals with schizophrenia andrecommends routine monitoring of these risks. They advise thathealth promotion advice be offered on smoking, alcohol, druguse and exercise3. The guidelines further state that individualstaking atypical antipsychotic medication should be offered acomprehensive package of care that addresses clinical, emotionaland social needs. In bipolar disorder, the British Association forPsychopharmacology has produced guidelines that emphasise themedical need to assume responsibility for physical examinationsto advise patients to maintain normal levels of exercise andmoderate calorie intake3. “The 2009 Schizophrenia PORTPsychosocial Treatment Recommendations and SummaryStatements” recommend a three month psychosocial treatmentfor weight loss management in those who are overweightor obese6. This intervention should include psychoeducationfocused on nutritional counselling, calorie expenditure and portioncontrol; behavioural self management including motivationalenhancement; goal setting; regular weigh-ins; self-monitoringof daily food and activity levels; and dietary and physical activitymodifications1,7. Furthermore, where psychiatric patients have orare at risk of metabolic syndrome, weight-neutral psychotropicmedications are recommended.

Clinical ResearchThe guidelines currently advise psychiatrists to routinely evaluatethe risk factors associated with metabolic syndrome. The fewinterventions that exist combine elements of health screening,education and promotion with behavioural initiatives; however,

the empirical evidence to support these is weak. Lifestyleprogrammes have been described as a cost-effective way ofproviding education about lifestyle changes to improve physicalhealth and mental well-being, however, the use of exerciseprogrammes with patients as an adjunct therapy in clinicalpractice remains limited. More importantly, the question of howthese strategies might be disseminated and implemented acrossdiverse clinical settings and patient populations has not beenaddressed.

The FutureIn order to address the physical needs of those with seriousmental illness there should be a greater focus on physical healthassessment and health promotion within the multidisciplinaryteam. This approach will need to primarily address patientengagement and sustained motivation but should also include amajor support role for carers as well as primary and secondaryhealth care workers and incorporate health service and healthpromotion initiatives specific to this population and their needs.The current evidence is that while most patients will accept entryinto an appropriate programme, engagement with the interventionis not sustained2. Yet, in light of the significant risks to physicalhealth it is incumbent on all health professionals, perhaps evenour ethical and moral responsibility, to find a way of encouragingpeople with mental illness to participate in and to completephysical health interventions. The role of motivational interviewingmay be central to success in this population and such initiativeswill likely need to build in components to address self esteem andconfidence as an initial step towards engagement. As with mostillness and health initiatives, prevention may be more beneficialthan cure.

The research to date illustrates the increased morbidity and earliermortality of people with mental illness1. A number of modifiablerisk factors have been identified, some similar to those in thegeneral population and some illness specific and complicatedby the metabolic side effects of medication1. Managing physicalhealth poses a significant challenge to frontline mental healthstaff and providers. The current guidelines do not give specificrecommendations on evidence based physical health interventionsnor do they address how interventions should be tailored tomeet the specific needs of these populations who in additionto facing the motivational challenges of healthy individuals, theyoften struggle with negative symptoms of their illness. Furtherresearch and evaluation in this area is urgently needed to enablethe development and delivery of a multidisciplinary and evidence-based intervention for patients and families that focuses onprevention and screening as well as management. The longerterm human and health care saving could be immense.

M McCormack, P Connolly, E Lawlor, M Clarke, A LaneThe Physical Health and Wellbeing Group, St. John of GodHospital, Stillorgan, Co DublinEmail: abbie.lane@sjog.ie

AcknowledgementsThe Physical Health and Wellbeing Group St John of GodHospital supported by a St John of God Research Grant.

References1. The cardiovascular health of young people with severe mental illness:

addressing an epidemic within an epidemic. The Psychiatrist 2012,375-378

2. Collins E, Tranter S, Irvine F. The physical health of the seriouslymentally ill: an overview of the literature. J Psychiatr Mental HealthNurs. 2011 Oct 18

3. Citrome L, Yeomans D. Do guidelines for severe mental illnesspromote physical health and well-being? J Psychopharmacol. 2005Nov: 19:102-9

Managing Physical Health in Mental Health Populations

102 Editorial / Original PaperIrishMedicalJournalApril2013Volume106Number4www.imj.ie

4. Thornicroft G. Physical health disparities and mental illness: thescandal of premature mortality. Br J Psychiatry. 2011 Dec; 199:441-2.

5. Wildgust HJ, Beary M. Are there modifiable risk factors which willreduce the excess mortality in schizophrenia? J Psychopharmacol.2011 Nov; 24:37-50.

6. Dixon L, Dickerson F, Bellack, A, Bennett M, Dickinson D, GoldbergR, et al. The 2009 Schizophrenia PORT Psychosocial TreatmentRecommendations and Summary Statements. SchizophrBull. 2010Jan; 36:48-70. Epub 2009 Dec 2.

7. Millar H. Management of physical health in schizophrenia: a steppingstone to treatment success. Eur Neuropsychopharmacol. 2008 May;18 Suppl 2: S121-8.

Bicycle Helmet Wearing in a Sample of Urban DisadvantagedPrimary School ChildrenMB Quirke1, S McGilloway1, CM Comiskey2, C Wynne2, K O’Sullivan2, E Hollywood21Department of Psychology, National University of Ireland, Maynooth, Co Kildare2School of Nursing and Midwifery, Trinity College Dublin, Dublin 2

IntroductionThe UK Department of Transport1 identified that, in 2008, 115pedal cyclists were killed and 2,450 seriously injured on roadsin Britain. In the Republic of Ireland, 7 road bicycle deaths wererecorded during the same year whilst, according to a HealthService Executive report2, an approximate average of 263 cyclistswere admitted annually to hospital with accident related injuriesduring 2005-2008. Hospital costs for these cases have beenestimated at over one million euro per year2. According to Elkeand Elvik3, children under fifteen are at greatest risk of seriousinjury through cycling-related accidents. At present, however, thereis no regulatory enforcement of helmet wearing for cyclists of anyage in the Republic of Ireland.

There is ongoing debate about the effectiveness of helmetwearing in reducing the risk of head injuries amongst cyclists1,4-6.In the Republic of Ireland, several medical and safety organisationshave consistently argued for compulsory protective headgear. Forexample, the Irish Medical Council7 argues that mandatory usagecan reduce the incidents of bicycle-related head injuries whilstthe Irish Road Safety Authority8 also promotes the use of bikehelmets by all cyclists. To support their position, the RSA8 presentevidence from two well known, albeit now dated, studies9,10whichconclude that wearing a helmet may reduce the risk of head injuryby 69%-85%. Furthermore, a more recent review of the literatureby the UK Department of Transport1, concludes that, overall, theuse of properly fitted and correctly used helmets is expectedto “be effective at reducing the risk of head injury, in particularcranium fracture, scalp injury and intracranial (brain) injury” (p1).However, other recent research suggests that any associationbetween bicycle helmet wearing and risk reduction may not beso clear-cut4,6,11. Many cycling associations argue strenuouslythat, where such laws have been introduced, they have not beenproven to reduce head injuries, but may instead, merely reducethe number of cyclists on the road12. Other critics of mandatoryenforcement highlight research evidence to suggest that theimproper use of helmets may increase the risk of other relatedinjuries such as strangulation13.

As this debate continues, there is still very little data availableon the helmet wearing practices of young children in Ireland

and associated risk factors14. Therefore, the principal aim of thisstudy was to assess self-reported helmet wearing by a sampleof primary school children and to explore factors which influencereported use.

MethodsChildren from 7 designated urban disadvantaged schools wereinvited to participate as part of a larger assessment of children’shealth behaviour15. Adapted versions of the self-report HealthRelated Behaviour Questionnaire16 and a Health Related Qualityof Life measure, the Kidscreen-2717, were completed by theparticipants (n=314). Questionnaires were completed in theschool setting in small groups with the research team present.The questionnaire was explained to the students using ageappropriate language and children were provided with additionalsupport to complete the questions when requested. The studywas conducted in accordance with the Psychological Society ofIreland Professional Code of Ethical Conduct and ethical approvalwas granted by Trinity College Dublin Health Sciences EthicalCommittee. Questions relevant to the current study were extractedand data were analysed using PASW19.

ResultsParticipants were aged 8-13 years (mean=10.27, standarddeviation=1.23) and 48% were female. A little over 86%(271/314) indicated that they owned a bike and of these 270provided a response to the question on helmet wearing. More thanone in five of this subsample (22%, 59/270) reported alwayswearing a helmet compared to 28% (75/270) who indicatedthat they only did so some of the time. However, half (136/270)reported never using protective headgear when cycling. Morethan one third (38%, 103/270) reported cycling more than threetimes a week although a little less than 5% (13/270) indicatedthey usually cycled to school. Chi-square analysis indicated nosignificant association between frequency of cycling and reportedhelmet wearing (c2(2, n=268), p=.46, phi=.07). Comparisonsacross age groups indicated that older children were less likelyto report wearing a bike helmet. For example, approximatelytwo-thirds (67%, 27/40) of 12- and 13-year-olds reportednever wearing a helmet compared with 38% (31/81) of 8- and9-year–olds (Figure 1). Chi-square analysis revealed that this

AbstractBicycle helmet wearing is currently not legally enforced in Ireland and little is known about the self-reported practice amongstyoung children. The principal aim of this study was to assess self-reported helmet wearing amongst a sample (n=314) of primaryschool children (aged 8-13 years) attending disadvantaged schools in Dublin. Approximately 86% of the sample owned a bike andprovided a response to the question on helmet use. The findings indicate that helmet wearing is not a widespread practice (50.4%;136/270 report never wearing helmets). As children get older, reported practice is also less likely with 67% (27/40) of 12/13year-olds compared to 38% (31/81) of 8/9 year-olds reporting never wearing protective headgear. Regardless of age, more girls(61%; 82/135) than boys (39%; 52/135) indicated always/sometimes using helmets when cycling. Conversely, the findings showthat (mandatory) seatbelt wearing is standard practice for the majority (93%; 252/270). The findings relating to helmet wearing addfurther to the debate around the mandatory introduction of protective headgear for cyclists.

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proportional change differed significantly across age groups [(3,n=270)=12.4, p=.006, phi=0.22], showing a decrease in reportedhelmet wearing as children got older, albeit with only a small tomoderate effect. Regardless of age, more girls (61%; 82/135)than boys (39%; 52/135) indicated always/sometimes usinghelmets when cycling.

The responses to a similar question on seatbelt-wearing showed,by contrast, that 93% (252/270) reported that they alwayswore a seatbelt whilst only one child said that they never worea seatbelt when in the car. No differences emerged betweengenders or across age groups. A direct logistic regression analysiswas conducted to assess the relationship, if any, between wearinga bicycle helmet (yes or no) and several possible predictors or riskfactors including: age; gender; frequency of cycling; frequencyof seat belt wearing; and a measure of parental support asmeasured from the Kidscreen-27. The model was statisticallysignificant (c2(9, n=268) =40.79, p

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to cycling and other health and safety behaviours. Furtherresearch should also explore how parental-perceived awarenessand acceptance of legally enforced versus voluntary practices,affects their children’s overall awareness of, and adherence to,appropriate cycle safety.

Correspondence: MB QuirkeDepartment of Psychology, National University of Ireland,Maynooth, Co KildareEmail: mary.quirke.2009@nuim.ie

AcknowledgementsThe children, parents, teachers and principals who very kindlyconsented to be involved in the study. This study was part of alarger evaluation research project commissioned by the ChildhoodDevelopment Initiative (CDI) for Tallaght West and funded by theAtlantic Philanthropies and the Office of the Minister for Childrenand Youth Affairs (OMCYA).

References1. UK Department of Transport. Cycle helmet wearing in 2008;

2009. [cited 2012 Feb 19]. Available from:http://webarchive.nationalarchives.gov.uk/20110509101621/http://www.dft.gov.uk/pgr/roadsafety/research/rsrr/theme1/PPR420.pdf

2. Health Service Executive. Admission to acute hospitals for injuriesas a result of road traffic collisions in Ireland 2005-2009. Navan:Department of Public Health; 2011. [cited 2012 January 26].Available from: http://www.hse.ie/eng/services/Publications/HealthProtection/Public_Health_/RTC-related_Hospital_Admissions_2005-2009,_A_Report.pdf

3. Erke A, Elvik R. Making vision zero real: Preventing pedestrianaccidents and making them less severe. Oslo: Institute of TransportEconomics; 2007.

4. Clark C F. Evaluation of New Zealand’s bicycle helmet law. NewZealand Medical Journal, 125. 1-10; 2012.

5. Curnow WJ. The Cochrane collaboration and bicycle helmets.Accident Analysis and Prevention, 37, 569-573; 2005

6. Elvik R. Publication bias and time-trend bias in meta-analysisof bicycle helmet efficacy: A re-analysis of Attewell, Glase andMcFadden, 2001. Accident Analysis Prevention.;43:1245-51; 2011

7. Irish Medical Council. Advocating for Change: IMO Position Papers2005-2010. Dublin: IMO; 2012[cited 2012 Feb 20]. Available from:http://www.imo.ie/news-media/publications/Advocating-for-Change.pdf

8. Road Safety Authority. Cycling safely booklet; 2010 [cited 2012 Feb20].http://www.rsa.ie/Documents/Campaigns/Wrecked/Downloads/Cycle%20safety%20booklet.pdf

9. Thompson DC, Rivara FP, Thompson RS. Effectiveness of bicyclesafety helmets in preventing head injury. A case-control study. JAMA,276, 1968-1973; 1996.

10. Thompson R, Rivara F, Thompson D. A case control study of theeffectiveness of bicycle safety helmets. New England Journal ofMedicine. 320(21), 1361-1367; 1989.

11. Smith NC, Milthorpe FW. An Observational Survey of Law Complianceand Helmet Wearing by Bicyclists in New South Wales – 1993.Sydney: NSW Roads and Traffic Authority; 1993

12. Bicycle Helmet Research Foundation. BHRF commentary on theUK Department of Transports document entitled: Bicycle helmets– a review of their effectiveness: a critical review of the literature;2003. [cited 2012 January 29]. Available from: http://cyclehelmets.org/1067.html

13. Byard RW, Cala A, Ritchey D, Woodford N. Bicycle helmets andaccidental asphyxia in childhood. Medical Journal of Australia;194, 49; 2011. [cited 2012 February 03]. Available from: http://cyclehelmets.org/1227.html

14. Kelleher C, Nic Gabhainn S, Friel S, Corrigan H, Nolan G, Sixsmith J,Walsh O, & Cooke M. National Health and Lifestyle Surveys: Survey ofLifestyle, Attitudes and Nutrition (SLÁN) & The Irish Health Behaviourin School-Aged Children Survey (HBSC); 2002. [cited 2012 Feb 15].Available from: http://www.nuigalway.ie/hbsc/documents/slan03pdf.pdf

15. Comiskey CM, O’Sullivan K, Quirke MB, Wynne C, & McGillowayS. The Healthy Schools Evaluation Final Report. A Report for theTallaght West Childhood Initiative [unpublished report].

16. Balding J. HRBQ – providing baseline data. Education & Health, 20, 4,71-71; 2002.

17. KIDSCREEN Group. Generic health-related quality of life instrumentsin children and adolescents: a qualitative analysis of content. Journalof Adolescent Health, 34, 37-45; 2004.

18. Road Safety Authority. Annual national seatbelt survey: Adult andchild survey results 2009. [cited 2012 Feb 21]. Available from:http://www.rsa.ie/Documents/Road%20Safety/Seatbelts/Seatbelt%20Survey%202009.pdf

19. UK Department of Environment. Northern Ireland Seatbelt SurveyApril 2011: Wearing rates in cars. [cited 2012 Feb 22]. Availablefrom: http://www.doeni.gov.uk/seatbelt_survey_2011_report.pdf

20. Parkin PC, Hu X, Spence LJ, Kranz KE, Shortt LG, Wesson DE.Evaluation of a subsidy program to increase bicycle helmet use bychildren of low-income families. Pediatrics, 96, 2, 283 -287; 1995.

21. Robinson DL. Bicycle helmet legislation: can we reach a consensus?Accident Analysis and Prevention, 39, 86-93; 2006

22. Rissel C, Ming Wen L. The possible effect on frequency of cyclingif mandatory bicycle helmet legislation was repealed in Sydney,Australia: a cross sectional survey. Health Promotion Journal ofAustralia, 22, 178-183; 2011.

23. Schieber RA, Sacks J J. Measuring community bicycle helmet useamong children. Public Health Reports, 116, 113-121; 2001.

24. Rivara FP, Astley SJ, Clarren SK, Thompson DC, & Thompson RS. Fitof bicycle safety helmets and risk of head injuries in children. InjuryPrevention, 5:194-7; 1999.Central Statistics Office.

25. Consumer price index; 2012. [cited 2012 Feb 27]. Available from:http://www.cso.ie/en/media/csoie/newsevents/documents/prcpijan2012.pdf

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IntroductionOvercrowding has become a problem in emergency departments(ED) in Ireland, primarily due to exit block. It can compromiseclinical care, patient access, patient satisfaction, patient dignity,staff morale, surge capacity, safety, cost efficiency, teaching andresearch1-6. In the UK, the National Health Service (NHS) set atarget to achieve the disposition of 98% of patients within fourhours of arrival at an ED7. In Ireland a target of 6 hours has beenadopted8. The international literature has identified a number ofways to alleviate ED overcrowding and facilitate flow by tacklinginput, throughput and output factors1,9. The choice of interventiondepends upon which delaying factors are particular to the ED andthe improvement process should begin by identifying exactly whatthese delaying factors are.

Lean thinking and Theory of Constraints (TOC) are processimprovement methodologies that aim to facilitate flow. Thesemethodologies can be applied successfully to the unpredictableneeds of healthcare10-12. They have both been used successfullyin the NHS13-16 and in EDs elsewhere17,18. In TOC terminology,according to Umble and Umble, the work being processedthrough a healthcare system can be defined as the patientsthemselves15; so there are constraints wherever patients arefound in queues. While TOC aims to increase the throughput byfocusing on the main constraint in the system11,19, lean thinkingaims to reduce the flow time by reducing waste at every pointthroughout the process10,19. The five focusing steps tool (5FS)provides the foundation for the TOC improvement process andthe first of these five steps is to identify the constraints11. Theremaining four steps are to exploit the constraint, to subordinateeverything else, to elevate the performance of the constraint, andto identify the next constraint. The aim of this study was to identifyand prioritise the bottlenecks in the patient’s journey through theED in a regional general hospital from the time of arrival to thetime of admission or discharge by using a method based on theNHS four hour rule7 and a significance test.

MethodsProcess maps of patients’ journeys through the ED and RadiologyDepartments and of their blood samples through the PathologyDepartment were developed in consultation with staff. Basedupon this, a value-stream map10 was drawn. Following this,patients who were seen by an ED doctor during a seven dayperiod in June 2006 were tracked from initial registration to theirdisposition (admission or discharge from ED). Non-routine datawere collected for this study by hospital staff using data collectionsheets attached to the patient’s clinical notes and x-ray requestforms. The UK four hour target was used for the purposes of thisstudy to split the sample into two groups with patient journeys ofunder and over four hours; i.e. between patients who were seenand managed in a timely manner (under four hours) and those

whose journey through the ED could be considered ‘too long’(over four hours).

The sample size calculation estimated that a sample size of400 subjects would be required to detect a difference of 20minutes total ED journey time (i.e. 15% difference) between thetwo groups with a power of 90% and at a 5% significance level.The population under study was defined as the total numberof patients seen in the ED during the calendar year 2005,i.e. 29,412 patients. In 2005, there were on average 80 EDattendances per day at Sligo General Hospital (29,412/365=80).At this rate of attendances it would take five days to achieve 400attendances. It was decided to extend the study period to sevendays to overcome the expected problem of missing data. In thisstudy, the term ‘turnaround time’ (TAT) is used to describe thetime a healthcare worker spends with the patient from the startof the assessment or investigation to the finish. This does notinclude the time from the request for assessment to the start ofthe assessment which is termed the ‘wait’.

The SPSS (version 14) statistical software package was usedfor analysis. All variables found to be significant predictors onunivariate analysis (Pearson Chi-square tests) were includedin a logistic regression model and backward stepwise logisticregression analysis performed using likelihood ratios. This wascarried out to establish which variables were predictive of totaljourney times longer than four hours. In order to identify wherebottlenecks appeared when the system was under pressure, eachstage of the journey was compared between the two groups. Theassumption was that when a patient’s total journey time exceedsfour hours, the time intervals at the bottlenecks would stretchto a greater degree than the stages that are not bottlenecks.By definition, some time component was going to be longer inthe over-four-hour group, however, the aim was to see if somesegments of the patient’s journey lengthened disproportionatelywhile others stayed the same. Mann-Whitney tests were usedbecause data were not normally distributed.

ResultsDuring the study period, a total of 599 patients passed throughthe ED, of whom 336 (56.1%) were males and 263 (43.9%)were females. The disposition time was non-routine data that wascollected manually for 434 (72.5%) patients so the total patientjourney time could be calculated for these patients only (72.5%of total). The remaining 165 patients (27.5%) left the ED withoutthe time being recorded. Of the 434 patients, the total patientjourney from registration to admission or discharge took underfour hours for 321 (74%) patients and over four hours for 113(26%) patients. Of the total sample of 599 patients, laboratorytests were ordered for 190 (31.7%) patients and radiologicaltests were ordered for 332 (55.4%) patients. One hundred and

STEPS: Lean Thinking, Theory of Constraints and IdentifyingBottlenecks in an Emergency DepartmentA Ryan1, K Hunter2, K Cunningham3, J Williams3, H O’Shea3, P Rooney3, F Hickey31Department of Public Health Medicine, Ballyshannon, Sligo2Health Protection Surveillance Centre, Dublin3Sligo Regional Hospital, The Mall, Sligo

AbstractThis study aimed to identify the bottlenecks in patients’ journeys through an emergency department (ED). For each stage ofthe patient journey, the average times were compared between two groups divided according to the four hour time frame anddisproportionate delays were identified using a significance test. These bottlenecks were evaluated with reference to a lean thinkingvalue-stream map and the five focusing steps of the theory of constraints. A total of 434 (72.5%) ED patients were tracked overone week. Logistic regression showed that patients who had radiological tests, blood tests or who were admitted were 4.4, 4.1 and7.7 times more likely, respectively, to stay over four hours in the ED than those who didn’t. The stages that were significantly delayedwere the time spent waiting for radiology (p=0.001), waiting for the in-patient team (p=0.004), waiting for a bed (p

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nineteen (19.9%) patients had both laboratory and radiologicaltests.

Logistic regression was carried out to identify which factors wereassociated with patients who were more likely to stay more thanfour hours in the ED. It showed that patients who had radiologicaltests were 4.4 times more likely to stay over four hours in the EDthan those who didn’t; patients who needed blood tests were 4.1times more likely to stay over four hours in the ED; and those whowere admitted were 7.7 times more likely to stay over four hoursin the ED. The time interval for each stage of the patient’s journeyis compared for the under and over four hours groups in figure 1.

There was a significant difference in the mean times betweenthe under and over four hours groups in four variables: wait forradiology, wait for the in-patient team, wait for a bed and the EDdoctor TAT (Table 1). A value-stream map of the patient journeywas developed, (Fig 2). The value adding stages are placed abovethe line and the non-value adding stages below the line10. Thenon-value adding stages of the patient’s journey are the periods

spent waiting for medical assessment (by ED doctor or in-patientteam), for diagnostics (X-ray or laboratory) or for a bed.

DiscussionThe lean thinking value stream map in (Figure 2) shows how thenon-value adding stages overlap with the bottlenecks identifiedin this study. The bottlenecks were identified as the four stagesin the patient’s journey that were significantly longer in theover-four-hours group. These were the ED doctor TAT; the waitfor radiological tests; the wait for assessment by an in-patientteam and the wait for a bed. Since the ED doctor TAT stageincorporates the time spent waiting for diagnostics results tocome back and since that may be where the true delay occurred,this bottleneck was not included in the prioritisation process. Theremaining three bottlenecks can be prioritised by looking at thesignificance test results. The most significant difference seenbetween the two four-hour groups was in waiting for a bed whichhad a p value of

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Two other limitations stemmed from the fact that non-routinedata had to be collected i.e. missing data and performance bias.It was assumed in the analysis that there was no systematicpattern in the missing data. The staff were aware that this studywas being carried out and this may have led to performance bias.This study combined the four hour timeframe with a significancetest to identify the bottlenecks in the patient journey throughthe ED. This four hour timeframe methodology pinpointed andquantified the bottlenecks by showing which steps stretch outand cause delays for patients and which steps seem to remainthe same regardless of how long the patient spends in the ED.The bottlenecks were long waits for radiology, for in-patient teamassessment and for an inpatient bed. Both lean thinking andTOC informed the interpretation of these bottlenecks and theimplementation of improvement measures.

Correspondence: A RyanDepartment of Public Health Medicine, Iona House, Upper MainSt, Ballyshannon, SligoEmail: aidana.ryan@hse.ie

AcknowledgementsAll the staff in Sligo Regional Hospital who collected data and toall the staff in the Department of Public Health Medicine HSE-West (Northwest).

References1. Plunkett P, Byrne D, Breslin T, Bennett K, Silke B. Increasing wait

times predict increasing mortality for emergency medical admissions.Eur J Emerg Med 2011; 18: 192-6.

2. Derlet R, Richards J. Overcrowding in the nation’s emergencydepartments: complex causes and disturbing effects. Ann Emerg Med2000; 35: 63-8.

3. Schull M, Slaughter P, Redelmeier D. Urban emergency departmentovercrowding: defining the problem and eliminating misconceptions.CJEM 2002; 4: 76-83.

4. Sprivulis PC, Da Silva JA, Jacobs IG, Frazer AR, Jelinek GA. Theassociation between hospital overcrowding and mortality amongpatients admitted via Western Australian emergency departments.Med J Aust 2006; 184: 208.

5. Richardson D. The access-block effect: relationship between delay toreaching an in-patient bed and in-patient length of stay. Med J Aust2002; 177: 492-5.

6. Guttmann A, Schull MJ, Vermeulen MJ, Stukel TA. Associationbetween waiting times and short term mortality and hospital admissionafter departure from emergency department: population based cohortstudy from Ontario, Canada. BMJ 2011; 342:d2983doi:10.1136/bmj.d2983.

7. Department of Health, Reforming Emergency Care: First steps to anew approach. London: Department of Health Publications; 2001.

8. Emergency Department Task Force, Emergency Department TaskForce Report. Dublin: Health Service Executive; 2007

9. Cooke M, Fisher J, Dale J, McLeod E, Szczepura A, Walley P, WilsonS. Reducing Attendances and Waits in Emergency Departments:A systematic review of present innovations. Warwick: University ofWarwick and University of Birmingham; 2005.

10. Jones D, Mitchell A. Lean Thinking for the NHS. London: NHSConfederation; 2006

11. Goldratt E, Cox J. The Goal: A Process of Ongoing Improvement.Great Barrington, MA: North River Press Inc; 1992

12. Silvester K, Lendon R, Bevan H, Steyn R, Walley P. Reducing waitingtimes in the NHS: is lack of capacity the problem? Clinician inManagement 2004; 12: 105-111.

13. Fillingham D. Can lean save lives? Leadership in Health Services2007; 20: 231-41.

14. Lubitsh G, Doyle C, Valentine J. The impact of theory of constraints(TOC) in an NHS trust. Journal of Management Development 2005;24: 116-131.

15. Umble M, Umble E. Utilizing buffer management to improveperformance in a healthcare environment. European Journal ofOperational Research 2006; 174: 1060-75.

16. Westwood N, James-Moore M, Cooke M. Going Lean in the NHS.Coventry: NHS Institute for Innovation and Improvement; 2007.

17. Rotstein Z, Wilf-Miron R, Lavi B, Seidman DS, Shahaf P, Shahar A,Gabay U, Noy S. Management by constraints: considering patientvolume when adding medical staff to the emergency department. TheIsrael Medical Association Journal 2002. 4: 170-3.

18. Parks JK, Klein J, Frankel HL, Friese RS, Shafi S. Dissecting delaysin trauma care using corporate lean six sigma methodology. J Trauma2008. 65: 1098-1105.

19. Nave D. How to compare Six Sigma, Lean and the Theory ofConstraints. Quality Progress. 2002 Mar; 73-8.

20. Acute Medicine Programme Working Group. Report of the NationalAcute Medicine Programme 2010. 2010 [cited 2012 Aug 8]Available from: http://www.hse.ie/eng/services/Publications/services/Hospitals/AMP.pdf

Prevalence of Subclinical and Undiagnosed OvertHypothyroidism in a Pregnancy Loss ClinicAS Khalid, C Joyce, K O’DonoghueAnu Research Centre, Department of Obstetrics and Gynaecology, UCC, Cork University Maternity Hospital, Wilton, Cork

IntroductionHypothyroidism is the second most common endocrine disorderin women of childbearing age and has long been associatedwith an increased risk of pregnancy loss. Recent interest hasfocused towards the relationship of subclinical hypothyroidismwith pregnancy loss. Subclinical hypothyroidism is defined by

elevated thyroid stimulating hormone (TSH), with normal freethyroxine (T4) levels. In overt hypothyroidism, free T4 is low.Thyroid autoimmunity is defined as the presence of thyroidantibodies regardless of thyroid status. The prevalence ofovert hypothyroidism, subclinical hypothyroidism and thyroidautoimmunity in pregnancy is 0.3-0.5%, 2-3% and 5-15%

AbstractRecent studies have associated pregnancy loss with subclinical hypothyroidism, defined as elevated thyroid-stimulating-hormone level,with normal free thyroxine. In overt hypothyroidism, the free thyroxine is low. Subclinical and overt hypothyroidism occurs in 0.25-2.5% and 0.2-0.3% of pregnancies respectively. We examined the prevalence of subclinical and undiagnosed overt hypothyroidismin women with recurrent miscarriage, late miscarriage and stillbirth attending the Pregnancy Loss Clinic. Data was collected from thePregnancy Loss Clinic records. Women with sporadic miscarriages, autoimmune disorders, thrombophilias and known hypothyroidismwere excluded. Two-hundred-and-sixty-two women were included. Median maternal age was 35 years (range 18-47). Subclinical andundiagnosed overt hypothyroidism was found in 11.45% of women. Twenty-two women (8.39%) had subclinical hypothyroidism, eight(3.05%) had undiagnosed overt hypothyroidism. Results were compared to women with ongoing pregnancies. A proportion of womenattending the clinic had subclinical or undiagnosed overt hypothyroidism, raising the suspicion of causation in unexplained pregnancyloss.

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respectively1. All rates are increased in women with pregnancyloss2-6.

The alteration in thyroid hormone regulation in pregnancy due tothe increase in plasma volume expansion, the increase in thyroidbinding globulin (TBG) caused by human chorionic gonadotrophin(HCG), and the relative iodine deficiency in pregnancy, results in a10-15% lower free T4 level compared to non-pregnant women7.The demands of thyroid hormone, however, increase due to theinitial increase in TBG, the thyrotropic action of HCG, whichcauses an increase in TBG and free T4 and alterations in thyroidmetabolism, particularly at placental level at later gestation7.Failure to adapt to these changes result in subclinical, or evenovert hypothyroidism in normally euthyroid women. Maternalhypothyroidism is associated with adverse pregnancy outcome,including pre-eclampsia, preterm delivery, placental abruptionand fetal death1-6,8-13. Fetal thyroid gland forms from week 7 ofgestation, and structurally matures at 17 weeks. Until the fetalthyroid produces sufficient endogenous thyroid hormone, thefetus depends on maternal thyroid hormone for its development14.

The incidence of pregnancy loss is 15-20%24. Recurrentmiscarriage, defined as at least three consecutive miscarriages,occurs in 1% of women24. Late miscarriage, or mid-trimestermiscarriage, defined as miscarriage between 14-24 weeks ofgestation, occurs in 1-5% of pregnancies. Stillbirth occurs in 1in 200 pregnancies. Both overt and subclinical hypothyroidismare associated with pregnancy loss, though the causativemechanisms remain unclear. Untreated hypothyroidism can causeanovulatory cycles resulting in subfertility. Even after conception,there is an increased prevalence of miscarriage14,15. Furthermore,hypothyroidism is more common in women aged 35 and above,when the risk of miscarriage also increases. Three proposedhypotheses for the association of thyroid autoimmunity andpregnancy loss are; firstly, it may reflect a generalised activationof the maternal immune system, secondly it delays conception,therefore increasing the risk of miscarriage due to older maternalage and thirdly, it may reflect a subtle deficiency in thyroidhormone16.

In overt hypothyroidism, treatment with levothyroxine is known toalleviate maternal symptoms and improve pregnancy outcome8. Insubclinical hypothyroidism, the evidence for treatment is lacking.However, The Endocrine Society Clinical Practice Guidelinesconcluded that there is benefit to treatment, with low incidenceof adverse outcomes, and therefore advocated levothyroxinetreatment in subclinical hypothyroidism1. Levothyroxinerequirements in patients with overt hypothyroidism increase fromearly first trimester and the dosage of levothyroxine may needto be increased 30-50% by 4-6 weeks gestation1,17,18. A targetlevel of TSH less than 2.5µU/mL is recommended4. In subclinicalhypothyroidism, the recommended timing of intervention anddosage remains unclear. We aimed to examine the prevalenceof both overt and subclinical hypothyroidism in women withpregnancy loss.

MethodsWe conducted a retrospective analysis of thyroid functiontests (TFT) in women attending the Pregnancy Loss Clinic(PLC) between January 2008 and December 2009. ThePLC in Cork is attended by women with a history of recurrentmiscarriage, late miscarriage, or perinatal death. Women with twoconsecutive first trimester miscarriages with no prior successfulpregnancies are also accommodated on request to facilitatelimited investigations and referral to the Early Pregnancy Unitin their subsequent pregnancy. The clinic is led by a consultantobstetrician specialised in maternal-fetal medicine, with support ofclinical midwifery specialists in bereavement and pregnancy loss.Women have the indicated medical investigations done at thetime of pregnancy loss to ensure availability of the results duringconsultation. Investigations include a thrombophilia screen, thyroid

function, autoimmune screening, and parental karyotyping. Resultsare routinely entered into the clinic database.

Data were collected retrospectively from the clinic database,supplemented by annual reports of perinatal deaths in 2008-2009, and by chart reviews where necessary. Women withrecurrent miscarriage, mid-trimester miscarriage and stillbirth wereincluded, while those with sporadic or non-recurrent miscarriagewere excluded. Recurrent miscarriage was defined as threeor more consecutive first trimester miscarriages, mid-trimestermiscarriage was defined as miscarriage between 14 to 24 weeks,and stillbirth was defined as intrauterine fetal death after 24weeks. Women with known thyroid and autoimmune disorderswere excluded. Women found to have other causative factorswere also excluded. Retrospective analysis was done as part ofclinical audit, for which local Research Ethics Committee approvalwas not required.

Thyroid function tests (TFT) were performed at the time ofdiagnosis of pregnancy loss. Only those found to be hypothyroid(overt or subclinical) were repeated at their follow-up PLCvisit. Thyroid peroxidise antibodies (TPO) were not performedin the routine investigations, and therefore not examinedin this study. TFTs were analysed in the Cork UniversityHospital biochemistry laboratory using the Roche ModularE170 electrochemiluminescent immunoassay. Trimesterspecific reference ranges provided by the manufacturer wereused to define hypothyroidism. Reference ranges for free T4and TSH in the first, second and third trimester used were12.05-19.60pmol/L and 0.33-4.59mIU/L; 9.63-17.00pmol/L and0.35-4.10mIU/L; and 8.39-15.60pmol/L and 0.21-3.25mIU/Lrespectively. A study to determine trimester-specific thyroidfunction reference ranges in the local pregnant population wasconducted concurrently, due to the lack of Irish data on thyroidfunction in pregnancy. Subjects from this cohort were then utilisedas controls25. Data was analysed using PASW Statistics 18package.

ResultsTwo-hundred-and-sixty-two women were included in thepregnancy loss cohort. Median maternal age was 35 years (range18-47). One-hundred-and-twenty-eight women (128/262; 49%)had recurrent miscarriage, eighty-nine (89/262; 34%) had alate miscarriage and forty-five (45/262; 17%) had a stillbirth. Inthe pregnancy loss population, median TSH was 1.74mIU/L andmedian free T4 was 15.20pmol/L. Median free T4 and TSH in therecurrent miscarriage, late miscarriage and stillbirth groups were15.70pmol/L and 1.60mIU/L; 14.00pmol/L and 1.69mIU/L;and 15.00pmol/L and 2.13mIU/L respectively (Table 1). Three-hundred-and-fifty-four patients were included in the controlgroup. Median maternal age was 30 years (range 17-45). Medianfree T4 and TSH in the first, second, and third trimesters were14.40pmol/L and 1.16mU/L, 12.90pmol/L and 1.16mU/L, and11.40pmol/L and 1.59mU/L respectively25.

Free T4 levels in the late miscarriage group and the stillbirthgroup were significantly lower than those in the recurrentmiscarriage group (p-value 0.001 and 0.03 respectively), likelydue to the later gestation of these pregnancies. Free T4 levelsbetween the late miscarriage group and the stillbirth group did notdiffer significantly. TSH levels did not differ significantly betweenall three groups. We compared the values of free T4 and TSH ineach pregnancy loss and control groups to the trimester specificvalues provided by the manufacturer (Table 1). Median TSH levelsin all pregnancy loss groups were higher than the assay medianin each trimester. The prevalence of subclinical and undiagnosedovert hypothyroidism in the pregnancy loss population was11.45% (30 /262), where 8.39% (22/262) were subclinical,and 3.05% (8/262) were undiagnosed overt. In the controlpopulation, 1.98% (7/354) were subclinical, and surprisingly2.82% (10/354) were overt. The prevalence of subclinical andundiagnosed overt hypothyroidism in the pregnancy loss group

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was significantly higher than the control group (p-value 0.0032).In the pregnancy loss group, 22.9% (60/262) had TSH levelsabove 2.5mIU/L, compared to 11.58% (41/354) in the controlgroup (p-value 0.003).

According to each pregnancy loss group, subclinical orundiagnosed overt hypothyroidism were diagnosed in 7.05%(9/128) women with recurrent miscarriage, 14.61% (13/89)women with late miscarriage and 17.77% (8/45) women withstillbirth. In the control group, 4.20% (5/119) women in the firsttrimester (p-value 0.4148), 1.72% (2/116) women in the secondtrimester (p-value 0.0006), and 8.40% (10/119) women in thethird trimester had low free T4 or elevated TSH (p-value 0.0983).Three of the 30 hypothyroid women also had fetal malformations;these were one case of anencephaly and two cases of cystichygroma. When examined according to maternal age, 85.71%(19/22) of the women with subclinical hypothyroidism were overthypothyroidism, 37.5% (3/8) were above 30 years of age.

DiscussionIn this study, the prevalence of subclinical and undiagnosedovert hypothyroidism in the pregnancy loss cohort was 11%, ofwhich 8% were subclinical. In the general pregnant population,the prevalence of overt and subclinical hypothyroidism isreported as 0.3-0.5%, and 2-3% respectively1. Our studydemonstrates a higher prevalence of subclinical hypothyroidismin a large observational cohort of women with pregnancyloss. These findings support the association of overt andsubclinical hypothyroidism with pregnancy loss. A previous studydemonstrated that in untreated hypothyroid women, 60% ofthe overtly hypothyroid women and 71% of the subclinicallyhypothyroid women had miscarriage2. In adequately treatedwomen, the risk was minimal2,8. In our study, 7% of womenwith recurrent miscarriage were either overtly or subclinicallyhypothyroid. Another study has demonstrated the prevalence ofhypothyroidism to be 4.12% in women with recurrent miscarriage.However there, only overt hypothyroidism was examined3.Another report showed that 3.8% of women with first trimestermiscarriages had subclinical hypothyroidism. In contrast to ourstudy, these authors included women with sporadic miscarriage6.

Interestingly, our study has also shown a higher prevalenceof hypothyroidism in women with late miscarriage (14%) andstillbirth (17%) compared to other reports, where 10% of womenwith late miscarriage, and 6% of women with stillbirths werehypothyroid10.

The risk of fetal death with increasing levels of TSH has beenreported5. Most recently, an increased incidence of pregnancyloss in women with TSH between 2.5-5.0 mIU/L in the firsttrimester was demonstrated, calling for redefining the upper limitsof TSH in the first trimester of pregnancy4. Our study showedthat 23% of women with pregnancy loss had TSH levels above2.5mIU/L, supporting the evidence that increased TSH alone canbe associated with pregnancy loss. We were unable to examinethe prevalence of thyroid autoimmunity in this population, asthis test was not routinely available at the time of the study.These findings support the debate on the benefits of screeningand subsequent treatment of abnormal thyroid function inpregnancy. Universal screening has never been clinically justifieddue to the lack of evidence supporting treatment of subclinicalhypothyroidism, and the lack of quality studies demonstratingits cost-effectiveness19,20. Targeted screening of women atrisk is advocated instead1,12,19,21. However, this can potentiallymiss 30% of those with thyroid disorders21. Universal screeningcan detect twice as many women with thyroid disorders in earlypregnancy compared to targeted screening21-23, but whethertreatment should then be initiated for all is unclear. Finally,as hypothyroidism in very early pregnancy affects pregnancyoutcome, some authors argue that screening should take placepre-conceptually. However, subsequent intervention remainscontroversial.

In conclusion, this study has demonstrated a significantprevalence of undiagnosed overt and subclinical hypothyroidism inwomen with pregnancy loss, supporting the association betweenpregnancy loss and hypothyroidism. Future research is neededto define optimal thyroid function levels in pregnancy, to justifythe most appropriate approach and timing of screening, and toevaluate the efficacy, safety, and the magnitude of benefit fromintervention.

Correspondence: K O’DonoghueAnu Research Centre, Department of Obstetrics andGynaecology, UCC, Cork University Maternity Hospital, Wilton,CorkEmail: k.odonoghue@ucc.ie

References1. Abalovich M, Amino N, Barbour LA, Cobin RH, De Groot LJ, Glinoer

D, Mandel SJ, Stagnaro-Green A. Management of thyroid dysfunctionduring pregnancy and postpartum: an Endocrine Society ClinicalPractice Guideline. J Clin Endocrinol Metab. 2007 Aug;92:S1-47.

2. Abalovich M, Gutierrez S, Alcaraz G, Maccallini G, Garcia A, Levalle O.Overt and subclinical hypothyroidism complicating pregnancy. Thyroid.2002 Jan;12:63-8.

Table 1 T4 and TSH values in pregnancy loss and control groups in comparison to relevant pregnancy trimester-specific reference standards,defined as median, 2.5% and 97.5% quartiles (Reference Intervals for Children and Adults Elecys Thyroid Tests, Roche; EstablishingTrimester Specific Maternal Thyroid Function Reference Intervals, Khalid et al, unpublished)

RecurrentMiscarriage

FirstTrimesterControl

First TrimesterReferenceStandard

LateMiscarriage

SecondTrimesterControl

Second TrimesterReferenceStandard

StillbirthThird Trimester

Control

Third TrimesterReferenceStandard

Median T4pmol/L 15.70 14.40 15.4 14.00 12.80 12.9 15.00 11.40 11.9

Range T4pmol/L 11.40 – 36.30 11.62-19.24 12.05- 19.60 8.40 -19.20 10.30-16.60 9.63- 17.00 10.20- 20.20 8.30-15.59 8.39- 15.60

Median TSHmIU/L 1.60 1.08 1.48 1.69 1.60 1.52 2.13 1.59 1.42

Range TSHmIU/L 0.41- 7.46 0.11-3.25 0.33- 4.59 0.32- 6.15 0.55-3.13 0.35- 4.10 0.39- 6.35 0.55-3.91 0.21- 3.25

1a 1b

Figure 1a Box plots demonstrating the distribution of TSH levels according topregnancy loss groups.

Figure 1b Box plots showing the distribution of free T4 according to pregnancy lossgroups.

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3. Rao VR, Lakshmi A, Sadhnani MD. Prevalence of hypothyroidism inrecurrent pregnancy loss in first trimester. Indian J Med Sci. 2008Sep;62:357-61.

4. Negro R, Schwartz A, Gismondi R, Tinelli A, Mangieri T, Stagnaro-Green A. Increased pregnancy loss rate in thyroid antibody negativewomen with TSH levels between 2.5 and 5.0 in the first trimester ofpregnancy. J Clin Endocrinol Metab. 2010 Sep;95:E44-8.

5. Benhadi N, Wiersinga WM, Reitsma JB, Vrijkotte TG, Bonsel GJ.Higher maternal TSH levels in pregnancy are associated withincreased risk for miscarriage, fetal or neonatal death. Eur JEndocrinol. 2009 Jun;160:985-91.

6. De Vivo A, Mancuso A, Giacobbe A, Moleti M, Maggio Savasta L, DeDominici R, Priolo AM, Vermiglio F. Thyroid function in women foundto have early pregnancy loss. Thyroid. 2010 Jun;20:633-7.

7. Glinoer D, de Nayer P, Bourdoux P, Lemone M, Robyn C, vanSteirteghem A, Kinthaert J, Lejeune B. Regulation of maternal thyroidduring pregnancy. J Clin Endocrinol Metab. 1990 Aug;71:276-87.

8. Negro R, Formoso G, Mangieri T, Pezzarossa A, Dazzi D, HassanH. Levothyroxine treatment in euthyroid pregnant women withautoimmune thyroid disease: effects on obstetrical complications. JClin Endocrinol Metab. 2006 Jul;91:2587-91.

9. Hollowell JG, LaFranchi S, Smallridge RC, Spong CY, Haddow JE,Boyle CA. 2004 Where do we go from here?--Summary of workinggroup discussions on thyroid function and gestational outcomes.Thyroid. 2005 Jan;15:72-6.

10. Feki M, Omar S, Menif O, Tanfous NB, Slimane H, Zouari F, ReziguaH, Chelly H, Kaabachi N. Thyroid disorders in pregnancy: frequencyand association with selected diseases and obstetrical complicationsin Tunisian women. Clin Biochem. 2008 Aug;41:927-3

11. Poppe K, Velkeniers B. Thyroid disorders in infertile women. AnnEndocrinol (Paris). 2003 Feb;64:45-50.

12. Allan WC, Haddow JE, Palomaki GE, Williams JR, Mitchell ML,Hermos RJ, Faix JD, Klein RZ. Maternal thyroid deficiency andpregnancy complications: implications for population screening. J MedScreen. 2000;7:127-30.

13. Glinoer D. Thyroid immunity, thyroid dysfunction, and the riskof miscarriage: a propos article by Vaquero et al. Mild thyroidabnormalities and recurrent spontaneous abortion: diagnostic andtherapeutical approach. Am J Reprod Immunol. 2000 Apr;43:202-3.

14. Glinoer D. The regulation of thyroid function in pregnancy: pathwaysof endocrine adaptation from physiology to pathology. Endocr Rev.1997 Jun;18:404-33.

15. Poppe K, Glinoer D. Thyroid autoimmunity and hypothyroidism beforeand during pregnancy. Hum Reprod Update. 2003 Mar-Apr;9:149-61.

16. Kaprara A, Krassas GE. Thyroid autoimmunity and miscarriage.Hormones (Athens). 2008 Oct-Dec;7:294-302.33.

17. Kothari A, Girling J. Hypothyroidism in pregnancy: pre-pregnancythyroid status influences gestational thyroxine requirements. BJOG.2008 Dec;115:1704-8.

18. Yassa L, Marqusee E, Fawcett R, Alexander EK. Thyroid hormoneearly adjustment in pregnancy (the THERAPY) trial. J Clin EndocrinolMetab. 2010 Jul;95:3234-41.

19. Stagnaro-Green A, Schwartz A. Is universal screening for thyroiddisease in pregnancy a cost-effective strategy? Nat Clin PractEndocrinol Metab. 2008 Nov;4:598-9.

20. Thung SF, Funai EF, Grobman WA. The cost-effectiveness ofuniversal screening in pregnancy for subclinical hypothyroidism. Am JObstet Gynecol. 2009 Mar;200:267 e1-7.

21. Negro R, Schwartz A, Gismondi R, Tinelli A, Mangieri T, Stagnaro-Green A. Universal screening versus case finding for detection andtreatment of thyroid hormonal dysfunction during pregnancy. J ClinEndocrinol Metab. 2010 Apr;95:1699-707.

22. Vaidya B, Anthony S, Bilous M, Shields B, Drury J, Hutchison S, BilousR. Detection of thyroid dysfunction in early pregnancy: Universalscreening or targeted high-risk case finding? J Clin Endocrinol Metab.2007 Jan;92:203-7.

23. Horacek J, Spitalnikova S, Dlabalova B, Malirova E, Vizda J, Svilias I,Cepkova J, McGrath C, Maly J. Universal screening detects two-timesmore thyroid disorders in early pregnancy than targeted high-risk casefinding. Eur J Endocrinol. 2010 Oct;163:645-50.

24. Regan L, Backos M, Rai R. The investigation and treatment of coupleswith recurrent first-trimester and second-trimester miscarriage. RCOGGreen-top Guideline. 2011. No 17.

25. Khalid AS, Marchocki Z, Lutomski J, Hayes K, Joyce C, Stapleton M,O’Mullane J, O’Donoghue K. Establishing Trimester Specific MaternalThyroid Function Reference Intervals. unpublished.

Factors Affecting Receipt of a Medical Card in a Cohort ofColorectal Cancer Patients, 2002-2006J McDevitt, L Sharp, D MacDonald, F Dwane, H ComberNational Cancer Registry, Building 6800, Cork Airport Business Park, Cork

IntroductionA cancer diagnosis can have significant financial implicationsfor individuals and their families. Direct costs may include costsof appointments with health professionals, hospitalisation, tests,procedures and treatment1-3 and out-of-pocket expenses.4-7 InIreland, 45% of cancer patients had paid to see a consultant orother hospital clinician, and 36% had paid to see a GP about theircancer.8 The average amounts spent were €465 for consultantfees and €250 for GP fees. In addition, almost 30% of patients

had had out-of-pocket expenses for supportive medications.8Approximately 30% of the population held a medical card in2007.9 Eligibility is means tested in those less than 70 years and,from the middle of 2001 until the beginning of 2009, entitlementwas universal on attaining 70th birthday. The level of medical cardcoverage for this age group rose from 79% in 2001 to 95% in2007.9 Cancer patients who were not already in possession ofa medical card at the time of diagnosis could apply for one onhardship grounds following diagnosis.10 The awarding of a card

AbstractThe criteria for allocation of medical cards to colorectal cancer patients

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to those who apply is administered throughcommunity welfare officers and the system isdiscretionary. In general little is known aboutpatterns of medical card possession amongcancer patients in Ireland, or about whichfactors determine receipt after diagnosis. Weidentified factors associated with possessionof a medical card before diagnosis in apopulation-based series aged under 70 yearswith colorectal cancer, the second mostcommonly diagnosed cancer in Ireland.11 Wealso – for the first time in Ireland – identifiedfactors associated with receipt of a medicalcard after date of diagnosis in those caseswho did not have one before diagnosis.

MethodsCases were abstracted from the NationalCancer Registry (NCR) on all invasivecolorectal cancers (ICD-02, C18 ‘colon’and C19-20 ‘rectum’) diagnosed between01/01/2002-31/12/2006 (figure 1).The NCR records all cancers diagnosed inthe population usually resident in Ireland.Completeness of registration is estimatedto be approximately 97%.12 Information wasabstracted on patient characteristics (e.g. dateof birth, gender), clinical details (e.g. date ofincidence, stage at diagnosis, tumour site).Using T,N,M data, cases were assigned anAJCC summary stage (I-IV)13; cases whereinformation on distant metastasis was notrecorded were assumed to be localisedtumours. As a proxy for income, quintilesof deprivation were derived for cases bylinking the address of the case at diagnosisto an electoral division (ED).14 Cases werecategorised by population density of their EDof residence based on census data for 2002.19

HSE area of residence (Dublin Mid Leinster (DNML), DublinNorth East (DNNE), South, West) was derived from address.Cases were categorised according to treatment received (surgery,chemotherapy and/or radiotherapy).

Cases were linked to the medical card master file maintainedby the PCRS, which included details of all medical cards incirculation between 01/01/2000 to 31/05/2007. All cardsassociated with each colorectal cancer case were identified. Eachcard had an issue date and an expiry date. A person was deemedto have had a medical card at the time of diagnosis if the date ofdiagnosis of the cancer occurred between the issue and expirydates of any card(s) registered to a case. Cases greater than 70years old at date of diagnosis were excluded. 3,215 cases whodid not have a medical card at diagnosis were followed from thedate of diagnosis until date of receipt of a medical card up until01/06/07 (one day after the date of last card issued) (figure1).Factors associated with possession of a medical card at thetime of diagnosis, and after diagnosis were investigated usingstepwise logistic regression. Variables were included in themodels if they were significant in likelihood ratio tests (at p

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diagnosis increased with age, from 21% in those under 55 yearsto 46% in those aged 65-69 yrs (OR=3.95; 95%CI;3.20-4.88),Males cases were marginally less likely to hold a medical card(OR=0.81;0.69-0.95). Unmarried cases held more medical cardsthan married cases; 45% vs. 27% respectively (OR=1.89;1.61-2.23). Almost half (47%) of those resident in the most deprivedareas held a medical card compared to 17% of those in the leastdeprived areas (OR=3.65;2.89-4.61). 44% of smokers held acard relative to 29% of non-smokers (OR=1.98;1.64-2.37). 38%of cases resident in ED’s with low population density (15/ha) (OR=1.47;1.20-1.80). HSE West (41%)and HSE South (35%) showed higher card possession comparedto DNML (26%) (OR=1.45;1.15-1.82 and OR=1.27;1.02-1.57respectively).

Medical card receipt after diagnosisOf the remaining 3,215 cases who did not have a card atdiagnosis 1,435(45%) subsequently obtained a medical cardbefore their 70th birthday at various times after diagnosis (figure1); 53% received it within 3 months of diagnosis, 74% within6 months, 82% within 9 months and 90% within 18 months ofdiagnosis (Figure 2). In multivariate analyses (Table 1), olderpersons (65-69yrs) were less likely to receive a medical cardrelative to younger persons (15-54yrs) (OR=0.77;0.62-0.96).52% of those resident in the most deprived areas held a medicalcard compared to 33% of those in the least deprived areas(OR=2.15;1.72-2.70). 57% of cases with stage IV diseasereceived a medical card compared to only 25% of cases withstage I (OR=2.49;1.85-3.36). Cases who received chemotherapy(OR=2.30;1.87-2.83) or radiotherapy (OR=1.40;1.13-1.72) weresignificantly more likely to obtain a card post-diagnosis. Casesresident in low population density EDs (

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reasons for this, we have highlighted unequivocally that regionaldifferences in medical card possession with colorectal cancer doexist.

Correspondence: L SharpNational Cancer Registry, Building 6800, Cork Airport BusinessPark, CorkEmail: linda.sharp@ncri.ie

AcknowledgementsP Burke for access to the medical card master file held by thePCRS. The tumour registration officers and other staff of the NCRinvolved in the collection and processing of the data on which thisstudy is based. This study was conducted under the auspices of agrant from the Health Research Board.

References1. Arndt V, Merx H, Stegmaier C, Ziegler H, Brenner H. Quality of life

in patients with colorectal cancer 1 year after diagnosis comparedwith the general population: a population-based study. J Clin Oncol.2004;22:4829-36.

2. Arndt V, Merx H, Stegmaier C, Ziegler H, Brenner H. Persistenceof restrictions in quality of life from the first to the third year afterdiagnosis in women with breast cancer. J Clin Oncol. 2005;23:4945-53.

3. Karesen R, Langmark F. Psychological, social and economic situationof women surgically treated for cancer. Tidsskr Nor Laegeforen.2000;120:2741-8.

4. Longo CJ, Derber R, Fitch, Williams AP, D’Souza D. An examination ofcancer patients’ monthly out-of-pocket costs in Ontario, Canada. EurJ. Cancer Care 2007; 16; 500-7

5. Brooks J, Wilson K, Amir Z. Additional financial costs borne by cancerpatients: A narrative review. Eur J Oncol Nurs. 2010 Nov 17

6. Moore KA. Breast cancer patient’s out-of-pocket expenses. CancerNurs 1999;22:389-96

7. Pearce S, Kelly D, Steven W. “More than just money” widening theunderstanding of the costs involved in cancer care. J Adv Nurs. 2001;33: 371-9.

8. Sharp L, Timmons A. The financial impact of cancer. National CancerRegistry/ Irish Cancer Society, July 2010. ISBN: 978-0-9554970-7-5

9. Health status and health service utilisation., Quarterly NationalHousehold Survey, Quarter 3, 2007. Central Statistics office ofIreland. Ref 210/ 2008.

10. Medical Card application form (MC1). URL:http://www.hse.ie/eng/services /Find_a_Service/entitlements/Medical_Card_GP_Visit_Card_Application_Form.pdf [Accessed Jan 2012]

11. Donnelly DW, Gavin AT, Comber H. Cancer in Ireland 1994-2004:A comprehensive report. Northern Ireland Cancer registry/ NationalCancer registry, Ireland; 2009

12. CompletenessQuality.pdf. National Cancer Registry. [Online] 2010.http://www.ncri.ie/pubs/pubfiles/CompletenessQuality.pdf.

13. TNM Classification of malignant tumours, 5th edition. Eds. Sobin LH,Wittekind C. International union against cancer.

14. Kelly A, Teljeur C. The National deprivation index for health servicesresearch. SAHRU Technical Report December 2007. Trinity CollegeDublin.

15. Brugha R, Tully N, Dicker P, Shelley E, Ward M, McGee, H. (2009)SLÁN 2007: Survey of Lifestyle, Attitudes and Nutrition in Ireland.Smoking Patterns in Ireland: Implications for policy and services,Department of Health and Children. Dublin: The Stationery Office.

16. Mitchell E, Macdonald S, Campbell NC, Weller D, Macleod U.Influences on pre-hospital delay in the diagnosis of colorectal cancer:a systematic review. Br J Cancer. 2008; 98:60-70.

17. Frederiksen BL, Osler M, Harling H; Danish Colorectal Cancer Group,Jorgensen T. Social inequalities in stage at diagnosis of rectal but notin colonic cancer: a nationwide study. Br J Cancer. 2008; 98:668-73.

18. Schwartz KL, Crossley-May H, Vigneau FD, Brown K, Banerjee M.Race, socioeconomic status and stage at diagnosis for five commonmalignancies. Cancer Causes Control. 2003; 14:761-6

19. National Cancer Registry/Northern Ireland Cancer Registry. All-Ireland Cancer Atlas 1995-2007.

General Practitioners’ Perspectives on Revised Entry andSelection Methods to Medicine and the HPATT Dennehy1, M Kelly2, S O`Flynn31South West Specialist Training Programme in General Practice2Discipline of General Practice, NUI Galway3Medical Education Unit, School of Medicine, University College Cork, Cork

IntroductionThe introduction in Ireland of a revised process to determineadmission to medical school has been contentious.1,2Reforms in2009 included the introduction of the HPAT (Health ProfessionsAdmission Test) coupled with an adjustment of the weightingapplied to the Leaving Certificate and a moderation of thecalculation of Leaving Certificate points.3 The HPAT is a 22 hourmultiple choice paper. It comprises three sections; 1. LogicalReasoning and Problem Solving; 2. Interpersonal Understandingand 3. Non-Verbal Reasoning4. It belongs to a family of selectiontools that test general mental ability. Other similar such tests

include the UMAT, used in Australia and the UKCAT which wasintroduced to Great Britain in 20065,6. Research in the area ofentry and selection to medical school is growing internationally.There is an increasing acceptance that the